DME Request Form

  • DME Request Form

  • Client Date of Birth*
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  • Order Date*
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  • Type of DME*
  • Date of most recent Face-to-face with Provider*
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  • Weight of Client: *
    Height of Client: *

  • Diabetes ICD-10 Codes*
  • Do we have a recent A1C level?*
  • What date was the most recent A1C drawn on? *
     - -
  • Has the client been testing their blood glucose with a standard monitor?*
  • Is the Client currently taking Insulin?*
  • Does the client have a history AND documentation of hypoglycemia of either of the following:*
  • How is the client receiving insulin?*
  • How is the insulin being administered?*
  • Diabetes: The client has a history of... (Check all that apply)*
  • Type of Cane or Crutch?
  • Cane Base/Type
  • Why is the client unable to use a regular toilet?*
  • Is the client physically confined to an area of the home?*
  • Does the client need any other items to be ordered with the hospital bed?*
  • Why does the client require a hospital bed?*
  • Which traction equipment is required?*
  • What type of traction Frame is needed?
  • Traction equipment needed to:*
  • List the underlying condition causing the client's pain*
  • Which position(s) are required?*
  • Where is the client's pain?*
  • Which condition(s) require(s) this positioning?*
  • How severe is the client's condition or pain?*
  • How long has the patient suffered from their condition or pain?*
  • How as the client's condition or pain progressed over time?*
  • Why does the client's condition necessitate a hospital bed?*
  • What kind of changes in body position does the client need?*
  • Why must position changes be achieved frequently and/or immediately?*
  • Bathing- What type of bathing product is needed?*
  • Bathing- What does the chair/bench need?*
  • Bathing- Select all reasonings client needs bathing bench/chair*
  • Walker or Rollator?*
  • Walker/Rollator ICD-10 Code:*
  • Which mobility-related activities of daily living (MRADLs) are impaired?*
  • Which of the following statement describes the patient's inability to complete there MRADLs?*
  • Wound Vac- Has the patient done Wet to Dry dressings on the wound(s)?*
  • Wound Vac- What type of Foam/Drape is needed*
  • Wound Vac- Size of Foam needed?*
  • Wound Vac- Does the patient also need White Foam?*
  • Wheelchair/Scooter- What is needed?*
  • Seat Depth*
  • Seat Height*
  • Standard Wheelchair Accessories*
  • Power Wheelchair Accessories*
  • What is the primary reason the patient needs a power mobility device (PMD)?*
  • Select all MRADLs in the home that are impaired*
  • Which of the following describes the pts inability to complete these MRADLs in the home? (Select only 1)*
  • Which of the following symptoms occur when the pt attempts ADLs?*
  • What interventions help alleviate these signs/symptoms?*
  • Have these signs/symptoms changed over time?*
  • How is the patient's mobility limited without a PMD?*
  • The patient has used the following in the past:*
  • Pressure Reducing Surface*
  • Does the patient have multiple stage 2 pressure ulcers or at least one Stage 3 or 4 Pressure Ulcer on the trunk of their body?*
  • PT/INR Machine- Has the patient been on Coumadin for at least 90 days?*
  • PT/INR Machine- Who is going to perform the POCT in the home?*
  • PT/INR Machine- Has the provider agreed to monitor the patient with POCT in the home for PT/INR? - Please note that most Coumadin Clinics will NOT continue to monitor patients if they have their own INR machine. If the pt is being monitored by a Coumadin Clinic, the PCP or Cardiologist may have to agree to take back monitoring*
  • Oxygen- What Does the Patient need?*
  • Oxygen- What DX codes does the patient have?*
  • Oxygen- Does the patient currently have O2 in the home?*
  • New Oxygen Setup- Does the patient need Portability?*
  • New Oxygen Setup- What kind of portability does the patient require?*
  • New Oxygen Setup- What is the Duration of Oxygen Therapy?*
  • New Oxygen Setup- What Method of Administration?*

  • Due to the information given, the client does not meet the requirements for insurance to cover this item. 

  • Should be Empty: